Biliary injuries

1. Biliary Injuries/Choledochal
Cysts

2. Historical perspective
 First planned cholecystectomy in the world was
performed by Carl Langenbuch in 1882.
 First choledochotomy was performed by Couvoisser
in 1890.
 First iatrogenic bile duct injury was described by
Sprengel in 1891.
 Prof. Dr. Med Erich Muhe of Boblingen, Germany,
performed the first laparoscopic cholecystectomy in
1985.

3. Biliary Anatomy
a. Right hepatic duct.
b. Left hepatic duct.
c. Common hepatic duct.
d. Portal vein.
e. Hepatic artery.
f. Gastroduodenal artery.
g. Right gastroepiploic artery.
h. Common bile duct.
i. Fundus of the gallbladder.
j. Body of the gallbladder.
k. Infundibulum.
l. Cystic duct.
m. Cystic artery.
n. Superior pancreaticoduodenal
artery.
Schwartz’s Principles of Surgery, 8th Ed.,McGraw-Hill Companies, 2005.

4. Stewart et al. Bile Duct Injuries During Laparoscopic Cholecystectomy
Classic anatomy of biliary tree is present in only 30% of individuals, so it may be said
that anomalies are rule, not the exception.
( Maingot’s abdominal operations)

5. Anatomy
 Calot's triangle
bounded by cystic duct,
cystic artery, and common
hepatic duct.
 Hepatocystic triangle
bounded by gallbladder wall
and cystic duct, liver edge,
and common hepatic duct;
the cystic artery (and hence
Calot's triangle) lies within
this space.
(Maingot’s abdominal operation)

6. Laparoscopic cholecystectomy Pros
and cons
 General advantages
Shorter stay in hospital
Faster recovery period
Reduced post-op recovery time
Less postoperative pain
Improved cosmetic outcome
 Disadvantage
Increase in serious bile duct complications and
injuries

7. Introduction
 Open cholecystectomy was standard practice for
treatment of symptomatic gall bladder disease until
late 1980’s.
 At present 90% of cholecystectomies performed by
LC which is one of the commonest surgical procedure
in world.
 widespread application of LC led to concurrent rise
in incidence of major bile duct injuries (BDI),which
are more complicated than after open procedures.
 Since its introduction and routine use in 1990s, the
incidence of biliary injuries has doubled from 0.2%
to 0.4%.

8. Classic Laparoscopic Injury
Mistaking common bile duct for the cystic duct

9. Thermal Injuries
 Inappropriate use
of electrocautery
near biliary ducts
 May lead to
stricture and/or
bile leaks
 Mechanical trauma
can have similar
effects
Lahey Clinic, Burlington, MA.1994

10. Bile duct injuries during
cholecystectomy
 In 1990s, high rate of biliary injury was due to
learning curve effect.
 Surgeon had 1.7% chance of a bile duct injury
occuring in first case and 0.17% at the 50th
case.
 However most surgeons passed through
learning curve, steady – state reached, but
there has been no significant improvement in
the incidence of biliary duct injuries.

11. Biliary Injuries during Cholecystectomy
 Open cholecystectomy has been associated
historically with 0.2% to 0.5% risk of postoperative
Biliary tract injuries.
 On other hand LC has been associated with 2.5-fold
to 4-fold increase in the incidence of postoperative
BDI compared with OC.

12.  These preventable injuries can be devastating,
increasing morbidity, mortality, and medical
cost, while decreasing the patient’s quality of
life.
 Biliary injuries will always exist, and we need
to be aware of the best methods to avoid,
evaluate, and treat them.

13. Incidence of IBDI following cholecystectomy (%)
Author IBDI incidence following
OC
IBDI Incidence following
LC
Mc Mohan et al,1995 0.2 0.81
Strassberg et al, 1995 0.07 0.5
Shea et al,1996 0.19-0.29 0.36-0.47
Targarona et al, 1998 0.6 0.95
Lillemoe et al, 2000 0.3 0.4-0.6
Gazzaniga et al, 2001 0.0-0.5 0.07-0.95
Savar et al,2004 0.18 0.21
Moore et al,2004 0.2 0.4
Misra et al,2004 0.1-0.3 0.4-0.6
Gentileschi et al,2004 0.0-0.7 0.1-1.1
Kaman et al,2006 0.3 0.6

14. Risk Factors for Biliary tract injury
 Surgeon related factors
 Lack of experience (learning curve)
 Misidentification of biliary anatomy
 Intraoperative bleeding
 Lack of recognition of anatomical variations of biliary
tree
 Improper interpretation of IOC
 Improperly functioning equipment

15. Risk for biliary tract injury
 Patient related
Acute and chronic cholecystitis
Empyema
Long standing recurrent disease -> fibrosis
Porcelain gallbladder
Obesity
Previous surgery
Male sex
Advanced age

16. The Effect of Acute Cholecystitis on Lap.
cholecystectomy complications
 Complication rate three times greater than for
elective LC.
 Early cholecystectomy (72 h) outcome better
than delayed cholecystectomy.
 Conversion rate to open cholecystectomy is
higher than elective cholecystectomy 35% vs
9%.

17. Risk Factors for biliary tract injuries
Anatomic Variations
Present in 18 – 39% cases
Dangerous variations predisposing to BTI are present in only 3-6% of cases
Abnormal biliary anatomy
Short cystic duct, cystic duct
entering in the right duct-
Accessory right hepatic duct
Arterial anomalies
Right hepatic artery running
parallel to the cystic duct
Anomalous or accessory right
hepatic artery

18. (Sabiston text book of surgery 19thedtn.)

20. Summary of Causes of Bile Duct
Injuries
 Misidentification of
Common bile duct
Common hepatic duct
An aberrant duct (usually on the right side)
 Technical failure such as
Slippage of clips placed on the cystic duct
Inadvertent thermal injury to CBD
Tenting of CBD during clip placement
Disruption of a bile duct entering directly into gallbladder fossa .
(Goal of dissection should be conclusive identification of cystic structure within
Calot triangle)
(If the cystic duct and cystic artery are conclusively and correctly identified before
dividing, more than 70% of bile duct injuries would be avoided )

21. Technique
 Four methods of identification of cystic structures
during cholecystectomy
1) Routine cholangiography
2) Critical view technique
3) Infundibular technique-> widely used
4) Dissection of main bile duct with visualization of cystic
duct or common duct insertion->
( increased chance of either thermal or retraction
injury to CBD, aberrant insertion of cystic duct can
also complicate this approach)

22. Routine intra-op cholangiogram (IOC)
Laparoscopic ultrasonography
 Performed routinely or not ?
 Done via presumed cystic duct
 If this happens to be CBD, injury has already occurred!!
 IOC does not identify all aberrant ducts
 Arterial anatomy not identified
 IOC does not prevent BDI but may reduce its severity ( if
correctly performed & interpreted, IOC can prevent
complete CBD transection)
 IOC  higher rate of intra-op identification of BDI 
decreased cost of treatment & shorter hospital stay

23.  If critical view not obtained due to inflamation or hostile anatomy
perform IOC prior to dividing cystic duct .
Routine IOC reduces CBD injuries from 0.58% to 0.39% (American
Medicare data base study)

24. Critical view of safety
 Calot’s triangle dissected free
of all tissue except cystic duct
& artery
 Base of liver bed exposed
 When this view is achieved,
the two structures entering GB
can only be cystic duct &
artery
 Not necessary to see CBD

25. (A)Usual anatomy when infundibular technique applied. Cyst duct-gallbladder
junction is characterized by a flaring tunnel shape(boldlines). Arrow represents
circumferential dissection of CD-gallbladder junction during infundibular
technique.
(B) Inflammation can pull CBD on the gallbladder creating similar flaring tunnel
shape. As a result, CBD mistaken for cystic duct, resulting in classic injuries.
CD, cystic duct;CHD, common hepatic duct. (Strasberg S. Error traps and vasculo-biliary
injury in laparoscopic and open cholecystectomy. J Hepatobiliary Pancreat Surg
2008;15(3):285;)

26. Cystic duct or CBD?
2 – 3mm wide 5mm wide CD > 5mm – Is it
CBD?
Even with low
cystic duct
insertion, CD
rarely goes
behind
duodenum
CBD goes
behind
duodenum
Duct behind
duodenum must be
CBD
Double cystic
duct very rare
-- 2 ducts seem to go
towards inflammed
Gallbladder – one
must be CBD
No vessels on Vessels on --

27. Classical LC BDI

28. Strasburg Classification
 Type A Cystic duct leaks or leaks from
small ducts in liver bed
 Type B Occlusion of aberrant right
hepatic ducts
 Type C Transection of aberrant right
hepatic ducts
 Type D Partial (<50%) transection of
major bile duct
 Type E Transection involve >50%
Subdivided as per Bismuth
classification into E1 to E5

29. Strasburg Classification, cont’d
E: injury to main duct (Bismuth)
 E1: Transection >2cm from
confluence
 E2: Transection <2cm from
confluence
 E3: Transection in hilum
 E4: Seperation of major ducts in
hilum
 E5: Type C plus injury in hilum

30. Class I CBD mistaken for cystic duct, but error recognized before CBD is divided.
Class II Damage to CHD from clips or cautery placed on duct. Often occurs
where visibility is limited due to inflammation or bleeding.
Class III Most common (60%), CBD mistaken for cystic duct. Common duct is
transected and variable portion that includes junction of cystic and common duct
is excised .
Class IV Damage to right hepatic duct , either because this structure is mistaken
for cystic duct, or injured during dissection.

31. Bile duct injury
 Prevention should be main point
 (much more important than treatment)
 ALL laparoscopic cholecystectomies ARE difficult!
 None of them is easy!
 If injury occurred, …
who should treat it?
when should it be treated?
how should it be treated?

32. Prevention
 30° laparoscope, high quality imaging equipment
 Firm cephalic traction on fundus & lateral traction on
infundibulum, so cystic duct perpendicular to CBD
 Dissect infundibulo-cystic junction
 Expose “Critical view of safety” before dividing cystic duct
 Convert to open, if unable to mobilise infundibulum or
bleeding or inflammation in Calot’s triangle
 Routine intra-op cholangiogram
 Intraoperative laparoscopic ultrasound (IOUS) .
Mastery of Surgery 6th ed.

33. Changing the Culture of Cholecystectomy:
Stopping Rules
 Safety and avoiding BDI should be paramount concern to
surgeon performing LC.
 LC can be converted to open procedure or even aborted if
local conditions present unacceptable risks of danger.
 As Strasberg points out, the negative effects of conversion
or even aborting procedure and placing a cholecystostomy
tube are minor compared with the negative effect of a BDI.
 Failure of progression of dissection, inability to grasp and
retract gallbladder, anatomic ambiguity, poor visualization
of field due to hemorrhage, should trigger the surgeon to
consider alternate approach.
 Conversion rate < 5% can be expected in hands of a well
trained laparoscopic surgeon.

34. Timing of Identification
• Intra-op
• Unexpected ductal structures seen
• Bile leak into field from lacerated or transected
duct
• Post-op
• Depends on continuity of bile duct &
• Presence or absence of bile leak

35. Presentation of Bile Duct Injuries
 About 25% recognized intraoperatively.
 About 25% discovered within 24 hours post- operative
 About 50% present weeks to years post-operative.
 Most BDI are not recognized intraoperatively, and patients sent home after or
within 24 hours.
 Patients who fails to recover within first few days or develop progressive vague
abdominal symptoms.
 Abdominal fullness, distension, nausea, vomiting, abdominal pain, fever and chills.
 Symptoms can leads to bilomas, biliary fistula, cholangitis, sepsis, or multi organ
system failure.
 Clinical presentation-
Biliary obstructions-> anorexia, jaundice, liver enzyme elevation
Bile leaks
Both can occur simultaneously
Concomitant vascular injuries (complicate matter)
 Obstruction secondary to biliary stricture appear weeks to month later and may
present with recurrent colangitis, obstructive jaundice, or secondary biliary
cirrosis.

36. Intraoperative Detection
 If experienced, convert to Open Procedure and perform
Cholangiography (determine extent of injury)
 If not experienced, perform cholangiogram laparoscopically with
intent of referring patient (placement of drains)
 Consult an experienced hepatobiliary surgeon
Quicker the repair, better the outcome!!!
 Acute Management
Biliary catheter for decompression of biliary tract and
control of bile leaks
Percutaneous drainage of intraperitoneal bile collection

37. Clinical Presentation (post-op)
• Obstruction
• Clip ligation or resection of CBD  obstructive
jaundice, cholangitis
• Bile Leak
• Bile from intra-op drain or
• More commonly, localized biloma or free bile
ascites / peritonitis, if no drain
• Diffuse abdominal pain & persistent ileus
several days post-op  high index of suspicion
 possible unrecognized BDI

38. Post-Operative Detection Plan
 Controlling sepsis, establish biliary drainage, postulate
diagnosis, type and extent of bile duct injury.
 Broad-spectrum antibiotics
 No need for an urgent laparotomy. Biliary reconstruction in
presence of peritonitis results a statistically worse outcome.
 No need for urgent with reconstruction of biliary tree.
Inflammation, scar formation and development of fibrosis
take several weeks to subside.
 Reconstruction of biliary tract is best performed electively
after interval of at least 6 to 8 weeks.

39. BDI Management
 Investigation
 Ultrasonagraphy and CT -- Ductal dilatation
intra-abdominal collection and dilatation of
biliary tree.
 Cholangiogram
 ERCP—biliary anatomy and assess
the injury
 PTC—define biliary anatomy
proximal to injury
 MRCP—noninvasive (can miss
minor leaks)
HIDA scan -- If doubt exists, HIDA scan can
confirm leak but not the specific leak site
 MR angiography—vascular injuries

40. When realise that there is an injury, ASK for HELP!
If possible do not try to repair, even you are experienced
An experienced and FRESH surgeon should repair the injury.
If it is impossible AND it is a difficult injury that you can not treat,
place catheters and refer the patient.
There is no ‘Tissue Lost’, primary repair (end to end CBD repair)
over T-tube???
stricture rate is high!!!
There is ‘Tissue Lost’, biliodigestive anastomosis:
choledocoduodenostomy/ Roux-en-Y
hepaticojejunostomy
Primary repair  high incidence of failure 
percutaneous or endoscopic balloon dilatation later

41. Preoperative Investigation and Preparation for the
Procedure
■ Communication with previous surgeon
■ Previous surgical report
■ Laboratory tests: bilirubin, alkaline phosphatase, ALT, AST,
albumin, coagulation parameters, white blood cell count
Principles of Repair
■ Anastomosis should be tension free, with good blood supply,
mucosa to mucosa and of adequate caliber.
■ Hepaticojejunostomy should be used in preference to either
choledochocholedocotomy or choledochoduodenostomy.
■ Anterior longitudinal opening in the bile duct with a long side-to-
side anastomosis is preferred.
■ Dissection behind the ducts should be minimized in order to
minimize devascularization of the duct.

42. Timing of Repair
Factors favoring immediate repair are:
(1) Early referral
(2) Lack of right upper quadrant
bile collection
(3) Simple injuries
(4) No vascular injury and
(5) Stable patient
Factors favoring delayed repair are:
(1) Late (less than 1week after injury) referral
(2) Complex injuries (types E4, E5)
(3) Thermal etiology
(4) Concomitant ischemic injury

43. Strasburg classification
Type A
No reconstruction
Treated
endoscopicaly
Type B & C
Potentialy serious injuries
More common since introduction
of LC
Type B
Silent
Asymptomatic atrophy of
involved liver
Compensated by
hypertrophy of normally
drained liver
Pain or cholangitis
many yrs. after injury
Type C
Biliary fistula
Volume less
Converted to
silent Type B
Persistence
Reconstruction
Type D
<25% 25% - 50% or
 Caused by diathermy or
Small bile duct
Type E (>50%)
Repaired primarily
Over T-tube
Reconstruction by
hepaticojejunostomy
B,C and E1 to E5 are major
biliary injuries

44. ERCP – multiple stents
• Lateral duct wall injury or
cystic duct leak 
transampullary stent
controls leak & provides
definitive treatment
• Distal CBD must be intact
to augment internal
drainage with endoscopic
stent

45. Simple injuries types A and D may be treated in community
setting when discovered intraoperatively by endoscopic or percutaneous
techniques when they present in postoperative period.
 Complex injuries that require hepaticojejunostomy for repair (types B and C
injuries and most to type E injuries).
More complex injuries types E1 and E2 may also be treated by nonsurgical
techniques when they present as strictures.
Notations >2 cm and <2 cm in types E1 and E2 indicate length of common
hepatic duct remaining.

46. Bile leak
Immediate intra operative diagnosis Delayed diagnosis
injurMinor y Major injury
Repair over
T-tube
No experienced
hepato-Biliary surgeon
Clip open duct
Drain
IV antibiotics
Transfer to tertiary centre
Experienced hepatobiliary
surgeon available
Call second surgeon
Roux-en-Y hepatico-
jejunostomy
Drainage
Low -output High-output
Observe
Resolve < 5-7 days Continued
ERCP
Duct of Luschka
Cystic duct stump leak
Suspected CBD injury
Sphinctrectomy
Stent± sphincterectomy
PTC to deliniate anatomy
Control drainage
Repair by experienced
hepatobiliary surgeon

47. Cholangiography (ERCP + PTC)
 Percutaneous transhepatic cholangiography (PTC)
 Defines proximal anatomy
 Allows placement of percutaneous
transhepatic biliary catheters to decompress
biliary tree  treats or prevents cholangitis &
controls bile leak

48. ERCP – clips across CBD
 CBD transection 
normal-sized distal CBD
upto site of transection
 Percutaneous
transhepatic
cholangiography (PTC)
necessary
 Surgery

49. Intraoperative repair

50. Surgical repair
Choledocho-choledochostomy

51. Surgical repair
Choledocho-duodenostomy

52. Biliary enteric anastomosis
 Most laparoscopic BDI –
complete discontinuity
of biliary tree
 Surgical reconstruction,
Roux-en-Y
hepaticojejunostomy
 Tension-free, mucosa-
to-mucosa anastomosis
with healthy,
nonischemic bile duct

53. Surgical repair
Hepatico-jejunostomy (Roux-en-Y)

54. Definitive management
 Goal
 Reestablishment of bile flow into proximal GIT
 In a manner that prevents cholangitis, sludge
or stone formation, restricturing & progressive
liver injury
 Bile duct intact & simply narrowed  percutaneous
or endoscopic dilatation

55. Treatment summary
 Strasberg Type A – ERCP + sphincterotomy + stent
 Type B & C – Traditional surgical hepaticojejunostomy
 Type D – Primary repair over an adjacently placed T-
tube (if no evidence of significant ischemia or cautery
damage at site of injury)
 More extensive type D & E injuries – Roux an-Y
hepaticojejunostomy over a 5-F pediatric feeding tube
to serve as a biliary stent

56. Summary
• Multidisciplinary management of BDI  expertise of
surgeons, radiologists & gastroenterologists
• Mismanagement  lifelong disability & chronic liver
disease
• BDI with lap. Chole  results of operative repair,
excellent in Specialist Centres

57. Choledochal Cysts
• Choledochal cysts are focal or diffuse dilatations of
the biliary tree
• Most commonly present in childhood but
increasingly being recognized in adults.
• represent significant clinical challenges where
proper evaluation and management are paramount
to prevent serious clinical sequelae.

58. Epidemiology
• incidence of choledochal cysts varies significantly
throughout the world.
• In Asia, incidence is as high as 1 in 1000 population
with 50% cases representing from Japan
• In Western Countries, choledochal cysts occur less
frequently with reported cases ranging from 1:13,000
to 1:150,000 population.

59. • Occur more commonly in females with a M:F
ratio of 1:3-4
• Classically present in childhood, but recent series
report as many as 25% of cases presenting in
adults.

60. Classification
• Proper management of choledochal cysts requires consideratio
of their classification.
• Original Classification by Alonso-Lej and associates exclusively
involved the extrahepatic duct
• The classification was revised by Dr. Todani and colleagues in
1977 to include intrahepatic cystic anomalies

61. Todani Classification
• Type I (50-85%): They are characterized by cystic or
fusiform dilation of the common bile duct.
• Type IA is defined by cystic dilation of the entire
extrahepatic biliary tree,
• Type IB is defined by focal, segmental (often distal)
dilation of the extrahepatic bile duct.
• Type IC is defined by smooth, fusiform (as opposed to
cystic) dilation of the entire extrahepatic bile duct.

62. Todani Classification
• Type II ( 2%): true diverticula of the extrahepatic bile duct
and communicate with the bile duct through a narrow
stalk.
• Type III ( 5%) : Cystic dilatation of the intraduodenal portion
of the extra hepatic common bile duct; also known as a
choledochocele
• Type IV (30-40%): Involve multiple cysts of the intrahepatic
and extrahepatic biliary tree; IV A > IV B
• Type V: Caroli’s Disease

63. • Type 1 A

64.  Type II

65.  Type III

66.  Type IV A

67.  Type IV B

68.  Type V

69. Pathogenesis
• Cause not currently known. Most cysts are congenital in
nature.
• It is unclear whether cases of choledochal cysts diagnosed
in adults are acquired or late manifestations of congenital
cysts.
• There may be multiple mechanisms involved in the
creation of biliary cysts
• The high incidence of biliary cysts in Asia suggests a role for
either genetic or environmental factors.

70. • Congenital weakness in the bile duct wall
• Abnormal biliary epithelial proliferation before bile duct
cannulation is complete
• Bile duct obstruction or distension in the prenatal or
neonatal periods
• Fetal viral infection
• Pancreaticobiliary maljunction

71. APBJ – Babbit Theory
• Pancreaticobiliary maljunction is defined as an
extramural junction of the pancreatic and biliary ducts in
the duodenum beyond the intramural sphincter function
• characterized by a long common channel (typically over 2
cm)
• Increased reflux of pancreatic juice into the biliary tree --
>

72. Associated Developmental
Anomalies
• Biliary atresia , Duodenal atresia, Colonic atresia,
Imperforate anus
• Pancreatic arteriovenous malformation, Heterotopic
pancreatic tissue
• Multiseptate gallbladder
• OMENS plus syndrome
• Ventricular septal defect, Aortic hypoplasia,
• Congenital absence of the portal vein
• Familial adenomatous polyposis
• Autosomal recessive and autosomal dominant
polycystic kidney disease

73. Presentation
• Classic triad : pain, jaundice, and abdominal mass. ( ~ 10%)
• Infants commonly present with elevated conjugated
bilirubin (80%), failure to thrive, or an abdominal mass
(30%).
• In patients older than 2 years of age, abdominal pain is the
most common presenting symptom.
• Intermittent jaundice and recurrent cholangitis are also
common, especially in patients with a type III cyst.

74. Diagnosis
• U/S abdomen : to detect the presence
• CT scan – more appropriate in adults.
• MRCP
• Cholangiography: gold standard , PTC or ERC in adults
and intraoperative cholangiography in small children
• Liver function tests

75. Operative Management
• Type I: excision of the cyst with its mucosa and
reconstruction by Roux-en-Y hepatico-jejunostomy
• Type II: excision of the diverticulum and suturing of
the CBD wall
• Type III: endoscopic sphincterotomy is done.
• Type IV: Extrahepatic biliary resection,
cholecystectomy, and biliary reconstruction
• Type V: Liver transplantation, hepatectomy